Healthcare from the perspective of a clinician encompassing both the capture of the clinical viewpoint as well as the technology to help clinicians capture knowledge at the point of care
The thoughts expressed are my own and do not necessarily represent those of Nuance

Tuesday, April 23, 2013

Excellent article that demonstrates the challenges facing scientists and data. Despite the data clearly showing the benefits far outweighing the risks parents opinion and decision is swayed by "social norms"

As a society, we respect the privacy of healthcare decisions; however, if we are to sustain adherence to the recommended immunization schedule as a social norm, we need to learn how to empower immunizing parents to become vocal and talk with other parents, including prospective parents, about why they chose to immunize their children

Wednesday, April 17, 2013

I’m fortunate enough to spend a lot of time interacting with physicians, entrepreneurs, and investors on the bleeding edge of digital health – and it’s a consistently thrilling experience.

At the same time, the continuous exposure to the imaginative and the extraordinary can also be a bit deceptive. Self-associating groups, as Sunstein has discussed, tend to adopt relatively extreme views, and it’s easy to envision this happening in Silicon Valley in general, and to digital health innovators in particular.

Consequently, it was probably healthy, and certainly arresting, to attend a breakout session on social media at recent a medical conference; the audience members were mostly practicing physicians, seemed passionate about patient care, and were explicitly interested in learning about social media. Yet, most of the clinicians were not prepared to embrace it, and many were poignantly struggling to come to terms with a phenomenon they recognized as important, yet which viscerally troubled them.

Their concerns seem to fall into four categories, two involving patients, and two involving physicians.

1. Patients Receiving “Bad” Information

Many physicians described the challenges of dealing with patients who had retrieved wrong or incomplete information from the internet. This turns out to be a remarkably common problem; doctors reported spending a lot of time undoing bad information.

The challenge was highlighted by the observation that 25% of Google searches for headache reportedly discuss brain tumors, even though such a diagnosis would be exceptionally uncommon. The thought was that while physicians have learned during their training to appropriately weigh pre-test probabilities, patients have not, and are likely to fixate on extreme diagnoses rather than those that are most likely.

It seemed to me that “Dr. Google” upset many doctors not only because it complicated office visits, but also because it fundamentally altered the traditional doctor/patient relationship; as one physician said – verbatim – “I’ve lost my authority.” It’s hard not to see this as a profound shift in perspective many experienced physicians understandably struggle to manage.

2. Patients Transmitting “Bad” Information

Many doctors in the audience were also visibly troubled by the ease with which patients could share “misleading” information, whether about medicine or the doctors themselves.

Despite the clear repudiation of a link between vaccines and autism, for instance, many patients continue to worry, a concern reportedly spurred on by an active internet anti-vaccine community.

Doctors were also fretting about the ease with which disgruntled patients could use the internet to besmirch reputations — one physician complained that when he Googled himself, the first links that came up were bad reviews he said represented a small number of extremely vocal patients.

3. Physicians Receiving Information Badly

While some senior physicians worried that young doctors might start to rely on tweets rather than peer-reviewed articles, it seemed that the most significant concern raised was the impact that the “internet culture” was having on the practice of medicine. “We need to teach students that traditional values are still important,” one audience member said (again, verbatim), suggesting that students have become progressively less reflective.

The use of mobile devices – what consultants call “phone hygiene” – emerged as a particular source of physician aggravation. Rounding residents would routinely look at the cell phones rather than pay attention to either the patients or the senior doctors, leading at least one doctor to prohibit the use of mobile devices on rounds – except for a 5’ phone break he built into the schedule, to accommodate what he described as the young doctors’ obvious addiction.

Another senior doctor, in a complaint evocative of this recent, much-discussed NYT article, noted that residents would routinely update her by text, rather than by phone. She suggested this reflected a more general trend of young physician disengagement, evidently preferring to interact with devices rather than with other people.

4. Physicians Transmitting Information Badly

The ability afforded by social media to share information rapidly and broadly was another source of concern. Many senior physicians worried young doctors might use social media in unprofessional ways – sharing things they shouldn’t, saying things they shouldn’t – potentially placing themselves and their institutions at risk.

In some cases, even seemingly innocent activities might be deemed inappropriate. One young physician offered as an example a (medically-related) internet survey research project he wanted to do. He said that while he could do this very easily, nearly instantly, and essentially for nothing using Google, he learned from his department this would violate institutional policy, and to conduct the research with the required protections in place would cost at least $25,000; naturally, the research has not progressed.

Monday, April 15, 2013

Right now, in the UK, the outbreak of measles has reached epidemic proportions. Nearly 700 people have come down with the highly contagious disease in south Wales, and that number may double. Measles can cause a nasty rash and high fever, and in children can cause ear infections, encephalitis, and death.

So right now would be the worst of all possible times to give Andrew Wakefield precious front-page space on a newspaper to promote his incredibly dangerous antivax nonsense. Yet that’s exactly what the UK newspaper The Independent did.

The good news is, after getting blasted by skeptics like Ben Goldacre, the press release was taken down. If you want you can still read it the drippingly antivax site Age of Autism (read that site at your own risk). I do want to point out that in an irony so thick it’s palpable, Wakefield refers to vaccine researcher Paul Offit as a millionaire, using the old “follow the money” tactic. Really, Mr. Wakefield? Do you really want us to do that?

Back to The Independent, they also ran an article about Wakefield and vaccines along with the press release. To be fair, the article does condemn Wakefield, and if read carefully it does do a somewhat decent job overall of discrediting him. But it does have to be read all the way through, which is not something most people do these days (I expect the comments below to this very post will prove my point pretty well). And the headline with the article was, “MMR scare doctor: this outbreak proves I was right”.

Great expose slating the press given to the disgraced Mr Andrew Wakefield - he was struck of by the General Medical Council for perpetrating a fraud yet the Independent gave him ink on the front page over the weekend

Tuesday, April 2, 2013

A new study from the Centers for Disease Control and Prevention finds no link between the number of vaccinations a young child receives and the risk of developing autism spectrum disorders.

Jeff J. Mitchell/Getty Images

A large new government study should reassure parents who are afraid that kids are getting autism because they receive too many vaccines too early in life.

The study, by researchers at the Center for Disease Control and Prevention, found no connection between the number of vaccines a child received and his or her risk of autism spectrum disorder. It also found that even though kids are getting more vaccines these days, those vaccines contain many fewer of the substances that provoke an immune response.

The study offers a response to vaccine skeptics who have suggested that getting too many vaccines on one day or in the first two years of life may lead to autism, says Frank DeStefano, director of the Immunization Safety Office of the CDC.

To find out if that was happening, DeStefano led a team that compared the vaccine histories of about 250 children who had autism spectrum disorder with those of 750 typical kids. Specifically, the researchers looked at what scientists call antigens. An antigen is a substance in a vaccine that causes the body to produce antibodies, proteins that help fight off infections.

The team looked at medical records to see how many antigens each child received and whether that affected the risk of autism. The results, published in The Journal of Pediatrics, were unequivocal.

"The amount of antigens from vaccines received on one day of vaccination or in total during the first two years of life is not related to the development of autism spectrum disorder in children," DeStefano says.

The finding came as no surprise to researchers who study the immune system, DeStefano says. After all, he says, kids are exposed to antigens all the time in the form of bacteria and viruses. "It's not really clear why a few more antigens from vaccines would be something that the immune system could not handle," he says.

The study also found that even though the number of vaccines has gone up, the number of antigens in vaccines has gone down markedly. In the late-1990s, the vaccination schedule exposed children to several thousand antigens, the study says. But by 2012, that number had fallen to 315.

That dramatic reduction occurred because vaccines have become much more precise in the way they stimulate the immune system, DeStefano says.

“ The sad part is, by focusing on the question of whether vaccines cause autism spectrum disorders, [researchers are] missing the opportunity to look at what the real causes are. It's not vaccines.

"I certainly hope that a carefully conducted study like this will get a lot of play, and that some people will find this convincing," Clayton says. That would let researchers pursue more important questions, she says.

"The sad part is, by focusing on the question of whether vaccines cause autism spectrum disorders, they're missing the opportunity to look at what the real causes are," she says. "It's not vaccines."

Autism Speaks, a major advocacy and research group, seems ready to move beyond the vaccine issue. Geraldine Dawson, the group's top scientist, praised the new study and says the result should clear the way for research on other potential causes of autism.

These include factors like nutrition, which can affect a baby's brain development in the womb, Dawson says. Other factors could include medications and infections during pregnancy, she says, or an infant's exposure to pesticides or pollution.

"As we home in on what is causing autism, I think we are going to have fewer and fewer questions about some of these things that don't appear to be causing autism," Dawson says.

More coverage and science referring to a recent study showing no link between vaccines and autism. This was covered in the SBM Site The Final Nail in the Coffin - sorry if some of yo have trouble getting to the site as it appears to be having problems

As one commentator articulated

"The sad part is, by focusing on the question of whether vaccines cause autism spectrum disorders, they're missing the opportunity to look at what the real causes are, It's not vaccines."

If you are interested in a detailed analysis of the science and statistical analysis the SBM article is excellent. The analysis

They sliced and diced the data in a variety of ways looking for correlations and didn’t find any

And does an in depth debunking of the lack of science in the broadside from antivaccinationists who's fear mongering seems to date back to the widely and roundly debunked falsification of data by Andrew Wakefield that was described as the most damaging medical hoax of the last 100 years. He was struck of the GMC register and barred from ever practicing medicine in the UK.

As David Gorski in his title the study had not intended to disprove the relationship between the "toxins" used as part of vaccine make up. This study came as close as one can to disproving that relationship:

Which brings us to “too many too soon.” It appeared to be a “hypothesis” that was impossible to falsify, but DeStefano et al came about as close as it’s ethically possible to do to falsifying the hypothesis. No wonder that all that antivaccinationists are left with are calls for “vaxed versus unvaxed” studies and pharma shill ranting.